Managed care ombudsmen—and similar consumer advocacy programs—can help caregivers navigate through the complexities of their loved ones’ insurance plans.

Has an insurance company ever denied coverage for a procedure you believed was medically necessary? Has a loved one ever had trouble getting a health plan to pitch in for a prescribed medication?

Tom Bridenstine, head of the managed care ombudsman program for the Commonwealth of Virginia, has a message for anyone who feels their insurance isn’t paying for everything it should:

“Get some backup.”

Ombudsman programs like his help even the odds when consumers disagree with their insurers. Most states have a such a program or some corresponding form of public advocacy, usually through the departments of insurance or departments of health.

That’s not to say that his office and insurance companies always have an adversarial relationship. In fact, Bridenstine says that Managed Care Health Insurance Plans (MCHIPs), which include HMOs and Preferred Provider Organizations, understand the value of an independent voice when there’s a question about coverage.

“One of our primary responsibilities is to make sure [the insured] understand all the benefits available to them,” Bridenstine says. “We want people to get the coverage they’re entitled to. And while we assist consumers with the appeals process, at the same time, when something’s not covered, we can clarify the reasons for a legitimate exclusion.”

The growing need for this specific form of consumer assistance has been sparked by the prevalence of managed care plans in the United States. Most recent national estimates suggest that over 165 million Americans now participate in PPOs or HMOs—up from approximately 70 million in 1992. When you consider that insurance policies are growing increasingly complex; our health care delivery system and its rules are still evolving; and employers change health plans ever more frequently, it’s not surprising that consumers are seeking authoritative advice.

“We find a lot of people simply don’t know what’s out there,” Bridenstine says. “And maybe they don’t understand, or they’re unaware, of exclusions, limitations, or maximums in coverage. In that case, at least they’ve heard it from us, an independent source. Some people might say, ‘Oh, the plan just didn’t want to pay for it.’ But often it’s not as simple as that.”

Help with Appeals

In addition to helping consumers to understand their rights, responsibilities, and coverage, a managed care ombudsman’s primary role is to assist with the difficult and time consuming process of filing and pursuing appeals.

The need for some kind of independent assistance is hard to argue with. While all MCHIPs are obligated to have an appeals or grievance process, consumers may feel these dealings are inadequate or unfair (often because the health plan may oversee the entire procedure). In some instances, plans may fail to inform consumers of their right to an appeal, and the process itself can take weeks or even months to come to an end. Those with pressing medical concerns may feel that a drawn out process presents a threat to their health. Finally, depending on the circumstances and the state, someone with a complaint may have little recourse to a later or independent review of the plan’s decision if an appeal is denied.

The ombudsman can alleviate at least some of these concerns, and help navigate the practical aspects of the process.

“First, we can cut through massive piles of documentation,” Bridenstine says. “Once the process is in motion, one of the biggest challenges is often just to physically sort through the stack, to work in chronological order. The paper trail can be overwhelming.”

While appeals have the greatest chance of success when the treatment in question is very specific or has a narrow time frame, the managed care ombudsman can make the most difference in those instances that occur in a “gray area” that depends on interpretation. This most often involves different definitions of what’s “medically necessary.”

The denial of certain kinds of prescription medication is perhaps the best illustration of the importance of interpretation. There are numbers of different arthritis drugs, for example, each varying widely in cost. If a physician doesn’t submit full documentation or fails to identify a specific drug as best for the patient, the health plan may interpret this as merely a request for the most expensive drug. In such an instance, the denial of coverage may be more a matter of “let’s see if the cheaper one works first,” rather than a blanket refusal.

“When there isn’t good communication between doctor and plan, or a lack of proper documentation, the insurance company may simply not know the full condition of the patient,” Bridenstine says. “Maybe they denied coverage because they didn’t have all the facts.”

It works the other way, as well. An ombudsman can point out those instances in which a person is covered but is unaware of it. This most often occurs when a person has switched employers or their employer has switched plans. There can be a lot of material to get through, and covered items often slip through the cracks. Aside from establishing a “hierarchy of drugs,” many managed care organizations choose what equipment or prescription drugs will be included in their benefits. Not all plans even offer prescription coverage.

Another key to helping with appeals is to show what exactly is being requested and why it was denied. Sometimes an HMO or PPO is paying for a treatment that normally is excluded, but just at a lower percentage.

The majority of what an ombudsman does amounts, in effect, to coaching. With 60 percent of Americans belonging to one plan or another, the need for an advocate who understands the nuts and bolts of how managed care is administered has never been greater.